Reflective journaling has long

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1 E d u c a t i o n a l i n n o v a t i o n s Reflective Journaling for Clinical Judgment Development and Evaluation Kathie Lasater, EdD, RN, ANEF; and Ann Nielsen, MN, RN Abstract Reflective journaling is a strategy used often in clinical education to gain insight into students clinical thinking; however, studies indicate that students may benefit from guided reflections. Numerous tools have been used to structure student reflection with varying results. This article describes the outcomes from using the Guide for Reflection based on Tanner s Clinical Judgment Model. The Lasater Clinical Judgment Rubric, created from the Model, is used to evaluate development of clinical judgment and provides language to communicate about clinical thinking with students. Senior immersion course competencies, also developed with language from Tanner s Clinical Judgment Model, offer a comprehensive package that fosters students clinical judgment development, facultystudent communication about clinical judgment, and evaluation of students clinical thinking. Received: August 29, 2006 Accepted: March 7, 2007 Dr. Lasater is Assistant Professor and Ms. Nielsen is Instructor, Oregon Health and Science University, School of Nursing, Portland, Oregon. Address correspondence to Kathie Lasater, EdD, RN, ANEF, Assistant Professor, Oregon Health and Science University, School of Nursing, 3455 SW US Veteran s Hospital Road, Portland, OR ; lasaterk@ohsu.edu. Reflective journaling has long been a strategy used in nursing education, especially in precepted clinical experiences, to allow faculty to understand and evaluate students clinical thinking. Although literature about reflection identifies learning as greatest following a critical incident (Brookfield, 1987; Dewey, 1997; Johns, 2004), many student journals demonstrate minimal reflection about learning, instead focusing on the chronological details of clinical experiences. Recently, the Guide for Reflection (Nielsen, Stragnell, & Jester, 2007), based on the Tanner (2006) Clinical Judgment Model, was developed and reported. The Lasater (2007a) Clinical Judgment Rubric, also based on Tanner s (2006) Model, offers guidelines and language used to provide feedback to students. The purpose of this article is to highlight the outcomes from faculty and student perspectives, based on nearly 2 years of implementation of the Guide for Reflection (Nielsen et al., 2007) and Lasater s (2007a) Clinical Judgment Rubric in evaluating students clinical thinking through journaling. Literature Review Early in the 20th century, Dewey (1997) stated, reflective thinking alone is educative (p. 2). Over time, others concurred, adding that reflection is essential to learning from experience, particularly in those situations in which the issues are ill defined, multilayered, and complex (Boud, Keogh, & Walker, 1985; Brookfield, 1987; Schön, 1987). What better descriptors for patient situations requiring clinical judgments? The nursing literature often identifies clinical learning as richest when reflection follows a trigger incident (Benner, 1984; Benner, Tanner, & Chesla, 1996; Tanner, 2006). Reflective Journaling A recent review of reflective journaling practices in nursing education identified numerous strategies (Craft, 2005). Faculty practices differ regarding use of prompts or probes for enhancement of student reflection versus open-ended writing requirements. Some students write effective open-ended journals and, with little provocation, reflect thoughtfully and analytically on their own with depth of understanding. Others tend to report a chronological description, unable to ascertain clinical implications or effects on their professional development. The nursing literature indicates that guidance can help students develop their reflective skills and thereby increase their clinical reasoning skills (Bilinski, 2002; Daroszewski, Kinser, & Lloyd, 2004; Kuiper & Pesut, 2004; Ruth-Sahd, 2003). Craft (2005) recommended guiding students until they are comfortable with the process. Some researchers provided suggested or required topics for written reflection (Daroszewski et al., 2004). Results from a research study about reflective journaling suggested students may need guidance beyond an initial orientation to fully explore their thinking (Jensen & Joy, 2005). None of the reflective writing strategies reviewed by Craft (2005) 40 Journal of Nursing Education

2 identified a reflective guide or developmental rubric based on a conceptual framework describing critical thinking or clinical judgment. To help students think more clearly about the complexity of their clinical judgments, Nielsen et al. (2007) wanted students to reflect on their clinical thinking in more evidence-based ways. Clinical Judgment Tanner (2006) recently completed an integrative review of clinical judgment research in nursing, citing over 120 articles. This review, coupled with Tanner s own extensive research, culminated in the design of Tanner s (2006) Clinical Judgment Model, which became the conceptual framework for the Guide for Reflection (Nielsen et al., 2007). As an outcome of her integrative review, Tanner (2006) asserted clinical judgments often are more influenced by what the nurse brings to the situation than the objective data at hand (p. 205). The nurses or nursing students should have an awareness of their own values, biases, and experiences and how these affect individual thinking about a patient situation. In addition, the nurse or nursing student should enter the situation prepared to care for the patient, with the necessary resources and references. Reflection provides an excellent way for students to analyze their care and expand their abilities to make clinical judgments. However, evaluation of the development of those abilities often poses a challenge for faculty. Evaluation of Reflective Journaling A literature search revealed few publications about faculty evaluation of clinical judgment, evidenced in written reflections and responses to students, that promote the development of clinical judgment. In one study evaluating levels of reflection in students journals, students were asked to write examples for each of Mezirow s seven levels of reflection after introduction of the approach by faculty. The result was decreasing numbers of higher level journal entries over time in most students (Jensen & Joy, 2005). The approach in this study provided students with prompts to promote metacognition at the various levels, but the prompts did not give students guidance to analyze the general process of their thinking. Other authors have evaluated the experience of writing (Schmidt, 2004). Some recommended evaluation of students writing should focus on student development, rather than on grading journals (Bilinski, 2002; Craft, 2005). Because reflective writing involves a level of student intimacy not required for other written work, faculty-student interactions related to reflection must build the trust necessary for sharing thoughts. Formal grading of student writing may inhibit productive dialogue (Craft, 2005; Fink, 2003; Pierson, 1998). Although little has been written about evaluation of clinical judgment through reflective writing, rubric tools have been developed to evaluate clinical judgment in other learning activities, such as simulation and clinical practicum experiences (Lasater, 2007a). Use of the Guide for Reflection and Lasater s Clinical Judgment Rubric The Guide for Reflection (Nielsen et al., 2007) is used at our institution as a communication tool during a two-term senior-level precepted immersion clinical experience. Students are also required to keep a clinical log detailing information about patients, learned skills, and accessed professional literature. The Guide (Nielsen et al., 2007) leads students to examine and explore a clinical situation to assist in their development of and confidence in their clinical thinking. In conjunction with this learning activity, the Lasater (2007a) Clinical Judgment Rubric is used to assess and communicate about student thinking and progress in the development of clinical judgment. The Rubric offers specific criteria for evaluating clinical judgment development, as well as clear language to communicate about it with students. In addition, students use the Rubric to identify goals for the next steps in their clinical judgment development. Students are introduced to the Clinical Judgment Model (Tanner, 2006) and the Lasater (2007a) Clinical Judgment Rubric during their junior year and interact with it during high-fidelity simulation scenarios and debriefings. Concept-based learning activities (Heims & Boyd, 1990), using Tanner s (2006) Clinical Judgment Model, are initiated the same year. The Guide becomes a natural outgrowth of their exposure to these tools. Use of the Guide (Nielsen et al., 2007) and the Lasater (2007a) Clinical Judgment Rubric involves reviewing the Clinical Judgment Model (Tanner, 2006), then directing students to select a patient care situation that requires them to exercise clinical judgment. Students choose to analyze situations such as discussing patient feelings about impending death from end-stage liver disease, responding to apnea and bradycardic spells in neonates, sudden changes in patient behavior, fetal monitoring in labor, or nipple versus gavage feeding a premature infant. Students then use the prompts in the Guide to help them explore and describe their thought processes regarding patient care decisions. We require students to write four guided reflections during a 10-week term; students submit two before midterm and two more by the end of term. Through the use of written feedback, faculty respond and further guide the students to think more deeply about the situation. Student reflections using the Guide (Nielsen et al., 2007) are not formally graded; however, students writing contributes to the accomplishment of the senior immersion course competencies, which are based on the Tanner (2006) Clinical Judgment Model and align with its language, as well as the Guide for Reflection (Nielsen et al., 2007) and the Lasater (2007a) Clinical Judgment Rubric. Thus, the students reflective journaling is used to track progress toward meeting course competencies in addition to demonstrating growth in the quality of their clinical judgments. Faculty feedback, whether handwritten or online, provides students January 2009, Vol. 48, No. 1 41

3 with questions for further consideration and general evaluative comments on their thinking and writing about patient care. Faculty use of language from the Lasater (2007a) Clinical Judgment Rubric allows students to identify the level of their own thinking and aspects of patient care on which they might focus to further develop their clinical judgment (Lasater, 2007b). Faculty-written feedback establishes a dialogue that can continue if students need more input about their thinking or the clinical situation. In addition, faculty make weekly visits to the clinical sites and engage students in postconferences to learn more about their thought processes. After several terms of implementation with senior immersion students, we describe the outcomes of such an exercise from faculty and student perspectives. Reflective Guide Outcomes Faculty Perspective Perhaps the most significant outcome of using the Guide for Reflection (Nielsen et al., 2007) is faculty s opportunity to view students thinking and clinical judgment. Used early in the term, students who are having significant difficulties with clinical judgments can be identified and support provided. In addition, faculty can observe development of clinical judgment. Although a linear correlation demonstrating development of student thinking in reflective writing does not always exist, faculty can often see how students build on their previous experiences to achieve creative solutions. For example, one student described the clinical judgments she made about allowing a 14-yearold boy with cystic fibrosis to control various aspects of his care. She described her consideration of client safety, adolescent development, the client s long-standing experience of illness, and his familiarity with treatment. Although the student identified that in her experience, people with chronic illnesses are experts in their own care and adolescents need to be involved in decisions about care, the safety of those decisions must also be considered. In the end, the student developed and negotiated a partnership relationship, allowing client decision making about some care issues, while also maintaining client safety. In addition, she recognized the benefits of the relationship to both the client and the nurse. A second outcome from students use of the Guide is faculty s ability to uncover misunderstandings or missed connections, and take the opportunity to help correct them. In one instance, a student described a client who was dehydrated, nutritionally deficient, and experiencing a seizure disorder but did not make a connection between the seizures and nutritional status, evidenced by lack of discussion of the client s laboratory values. In another example describing a client with endstage liver disease who had a blood pressure reading of 77/58 mmhg, the student did not make the link between the client s low blood pressure and his history of gastrointestinal bleeding. When there are significant concerns about student understanding or actions in a given clinical situation, faculty ask the student for further written discussion of decision making, guide the student through comments and questions, direct the student to readings that might help him or her understand the situation better, or explore the issue further in person. If appropriate, faculty involves the preceptor in providing more specific support of development of student clinical judgment. Although preceptors are usually not directly included in the dialogue using the Guide for Reflection (Nielsen et al., 2007), faculty can use the information gleaned in student writing to help preceptors formulate questions during clinical experiences to stimulate student thinking and judgment. Third, faculty can trace students thinking about a client situation and clinical judgment, understanding that each is socially embedded and context specific (Tanner, 2006). For example, a student was caring for a premature neonate whose mother had been labeled in the report as difficult. Through reflective journaling, the student described the mother, who began the day with demands of the staff and dissatisfaction with her infant s care, as she became an eager learner about prematurity and care of the infant. Through talking casually and attentively to the mother and developing a therapeutic relationship with her, the student discovered how frightened and worried the mother was and realized the critical behavior was a response to lack of control in a stressful situation. The Table offers a sample of the dialogue between a student and faculty. The reflective guide headings were used by the student and faculty, with responses and feedback based in the rubric language. A fourth outcome is students development of rationale for interventions through use of the Guide (Nielsen et al., 2007). The Model describes several reasoning strategies nurses use in client situations, the most controversial of which may be intuitive reasoning. Although no faculty would deny the importance of students attention to gut feelings, student intuition should usually be confirmed with evidence so the theorypractice link is made. In the case of an older student from another profession, her intuition was well developed and generally accurate; thus, she counted heavily on her considerable intuitive skills, which sometimes led her to make assumptions. Early in the term, she was trying to get the physician s help with an out-of-control client. She later wrote about this situation, upset with its handling, as evidenced by inflammatory language describing the unresponsive actions by the physician. The faculty responded, asking what demands were important from the physician s perspective that evening. The student had the opportunity to talk with the physician a week later and learned the medical priorities for client care during that shift were fraught with multiple complex patients. She later wrote that she will never again accuse the physician of ignoring calls for assistance, but rather call the next physician in line. She acquired some insight about the complexity of the health care team s role, which will enable more constructive collaboration in the future. 42 Journal of Nursing Education

4 Table Example of Student Reflection and Faculty Responses Situation- Neither of us [student and preceptor] had ever met this mother before or taken care of this baby. We had background on this patient and had seen the very emotional responses she evoked in several of the nurses in the unit. She had [dismissed] several nurses for [a variety of reasons]. She had made formal complaints about unit staff. The mother took a very confrontational approach with staff. Background- Student s previous experiences: [While] it s good to be forewarned about patients families possible issues, it is also best not to act on preconceived notions that paint someone as difficult. (You are expressing your values and making good use of previous professional experiences. You may want to describe what they were.) Many times people act out when fearful or confused. I ve seen people many times in my life spoiling for a fight that just broke down when they realized that they were not going to get one and that you were on their side. (Thoughtful identification of applicable previous personal experience.) I was a little nervous at first because the mom had specifically indicated the she didn t want any students near her baby. (Very important to identify your emotions when approaching this type of clinical experience. It might be tempting to respond by avoiding this mother.) Noticing- Initially I noticed that the mom was very defensive and very particular about the way things were done for her baby. (Do you think this may have been her way of attempting to gain control of a difficult situation over which she had limited control?) She definitely had strong ideas about how things should be done. Also when introduced to me, she was very unfriendly, did not smile and say hello, and just eyed me in a way that I could only describe as angry or suspicious. (You are considering both subjective and objective data.) I engaged her in small talk told her I had a [child], then [engaged the mother in a casual parent-to-parent discussion]. (You chose to discuss a safe topic and did a little self-revelation in an attempt to build trust. Thoughtful approach!) That s when I noticed that what appeared at first to be a very strong wall of confidence was really composed of a great deal of fear and uncertainty. (You are interpreting subtle patterns insightfully.) Interpreting- We saw that we did not have a mother who needed to be challenged or ignored, we had a mom that needed some confidence-building and empowerment. (You have prioritized relationship building with this mother, which is very relevant and imperative to any other nursing responses. You are interpreting thoughtfully and basing your response on that interpretation.) As the day went on, the mom revealed to us more of her fears. (You have built enough trust for her to begin to tell you how you can best support her.) Because she only had her earlier healthier babies to compare to this situation, she didn t know what to worry about so she worried about everything. (You are beginning to glean more important information about what her other, more concrete needs are what she needs to know to begin to feel more comfortable caring for her baby. Worrying about everything is not an uncommon response for parents.) Responding- Goals for care: Empowerment Decreased feelings of being out of control increase parental involvement in infant care Increased parental involvement in infant care Family education about premature neonates and about the unit itself (You choose to categorize these as your responses, however your writing in this reflection demonstrates the circular nature of clinical judgment in that you have been noticing, interpreting, responding throughout your descriptions up to this point, as well. You describe clear communication; calm manner; thoughtful, well-planned interventions; and skillfulness in your responses.) Reflection-in-action- By midday, the mom was working with [us] instead of ordering us around (You are seeing a distinct change in this mother, likely a result of your responses to her.) The mom was asking many questions (Now you can really begin to work with this mother and support her learning and relationship with her baby.) The mom welcomed our care the next day. (How did this feel?) Reflection-on-action- I learned to exercise restraint in getting caught up in negative discussions with other staff members. When people do negative things we don t understand, we should always explore the reasons why. People can be strongly motivated by fear and other intense emotions. I will remember to approach patients with a different attitude but do what I can to discover the root of this emotion and help them resolve it. *The student s narrative is in regular typeface. Faculty responses are in bold. Specific verbiage from the Lasater (2007a) Clinical Judgment Rubric used to respond to the student is in bold and italicized. Fifth, one of the most satisfying outcomes of students analyzing their learning through use of the Tanner (2006) Clinical Judgment Model is the discovery and description of their significant learning moments. For example, through the process of examining her behavior in relationship to the physician s, the student in the above example saw her role in the less-than-optimal outcome and identified a new strategy for presenting a January 2009, Vol. 48, No. 1 43

5 client issue necessitating immediate attention. Reading reflections and providing feedback requires faculty time. Prior to integration of the Guide for Reflection (Nielsen et al., 2007) into the course, senior students were required to write clinical narratives in which they described their experiences, including some unguided reflection on patient care. In the authors experience, the requirement of structured reflective writing using the Guide for Reflection (Nielsen et al., 2007) has not markedly increased faculty workload, but the added insight into student thinking and learning makes any increase a valuable trade-off. Student Perspective Students report that using the Guide (Nielsen et al., 2007) and the Lasater (2007a) Clinical Judgment Rubric gives them a framework for evaluating their clinical judgments and learning from them, seeing their own progress, and developing confidence. They appreciate the communication platform that the Clinical Judgment Model (Tanner 2006), the Guide for Reflection (Nielsen et al., 2007), and the Clinical Judgment Rubric (Lasater, 2007a) provide, stating: Although I reflect on situations often, this Model helped me to further explore situations and has guided my plans for improvement in the future I like this Guide and Rubric far more than the formal nursing process models. It is more userfriendly because it uses everyday language and is less rigid [than the nursing process] thus allowing integration into real-life situations. [The Guide] helped me to distinguish between areas where I was doing well and areas that I needed to learn more about. Students appreciate the basis for dialogue with faculty and preceptor; for example, one student stated: Thank you for asking me to answer some additional questions as it really pushed me to better understand the pathophysiology behind what was happening. Some students prefer having a structure to help with reflection. The Guide helped me analyze some of the nursing situations I encountered. Students also report that using the Guide requires a significant amount of time. One student stated, Reflections were time consuming but definitely worth the effort. Another said, After the first paper, it was easier each time. In one faculty s experience, students have asked that other writing, such as course logs, be decreased to compensate for the time, rather than decreasing the reflective writing requirements. Conclusion We discovered valuable student learning, improved evaluation of clinical thinking, and enhanced communication about clinical judgment development were the outcomes when a reflective guide and developmental rubric, rooted in an evidence-based conceptual framework, were used. As part of our own development as faculty, we often exchange anonymous student journals, with their consent, to gain new perspectives about feedback to students. Faculty responses to student writing and thinking are also compared. As a result of the outcomes from using the Guide for Reflection (Nielsen et al., 2007) and the Lasater (2007a) Clinical Judgment Rubric, faculty colleagues from other nursing contexts, such as community health, are beginning to use these tools as well. The next step is curricular integration, which introduces Tanner s (2006) Model, Nielsen et al. s (2007) Guide, and Lasater s (2007a) Clinical Judgment Rubric early in students education and offers them the ability to note their progress throughout their educational experience. References Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison- Wesley. Benner, P., Tanner, C., & Chesla, C. (1996). 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